Most major CV guidelines mention but do not incorporate shared decision-making
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Key takeaways:
- Only half of major CV guideline documents mention shared decision-making as part of clinical practice.
- More guidelines should incorporate shared decision-making when appropriate.
Approximately half of all guidelines published by three major CV societies during the past decade mention “shared decision-making,” yet just 6% of recommendations incorporated shared decision-making in any form, researchers reported.
In a cross-sectional study that assessed 65 CV guidelines published by international CV societies, 51% broadly supported the importance of shared decision-making; however, among 170 recommendations that incorporated the phrase, most “merely noted the importance of patient preferences,” Ricky D. Turgeon, BSc(Pharm), PharmD, ACPR, clinical pharmacy specialist and assistant professor at the University of British Columbia, Canada, told Healio.
“The reality is that many decisions around chronic CV pharmacotherapy — the bulk of the guideline recommendations assessed in our study — are well suited for shared decision-making, since these medications are generally effective, but they don’t work for everyone and come with trade-offs in the forms of adverse effects, cost and pill burden,” Turgeon told Healio. “Despite this, shared decision-making is by no means the norm in current practice in cardiology or most health care disciplines. Guidelines are useful tools to help standardize practice, so in theory there is a lot they could do to help busy clinicians incorporate shared decision-making into practice.”
Reviewing the guidance
In a cross-sectional study, Turgeon and colleagues assessed the latest guidelines or subsequent updates that included pharmacotherapy recommendations published from 2012 to 2022 by the American College of Cardiology, Canadian Cardiovascular Society (CCS) and European Society of Cardiology, including 65 guideline documents. Researchers identified all pharmacotherapy recommendations within each guideline. Recommendations that incorporated shared decision-making were rated according to a systematic rating framework to evaluate the quality of directness (range, 1-3; assessing whether shared decision-making was incorporated directly and impartially into the recommendation’s text); and facilitation (range, A-D; assessing whether decision aids or quantified benefits and harms were provided, with A indicating that a decision aid quantifying benefits and harms was provided). Researchers also assessed the proportion of recommendations incorporating shared decision-making according to guideline society and category.
The findings were published in JAMA Network Open.
Of the 65 guideline documents, 33 documents (51%) incorporated shared decision-making in a general statement or within specific recommendations. Of 7,499 recommendations, 35% of recommendations addressed pharmacotherapy. Of these, 6% incorporated shared decision-making.
By category, general cardiology guidelines contained the highest proportion of pharmacotherapy recommendations incorporating shared decision-making (10%), whereas HF and myocardial disease contained the least at 3%.
The proportion of pharmacotherapy recommendations incorporating shared decision-making was comparable across societies, at 8% for ACC, 9% for CCS and 5% for ESC, with no trend for change over time. Only 3% of shared decision-making recommendations were classified as grade 1A , meaning impartial recommendations supported by a decision aid, whereas 67% were classified as grade 3D, meaning shared decision-making was mentioned only in supporting text and without any tools or information to facilitate.
Incorporate shared decision-making when appropriate
“The main takeaway from our study is that cardiovascular guidelines are doing better compared with previous studies in mentioning the importance of shared decision-making, but few recommendations actually incorporate shared decision-making in some form or another, and even fewer provide the tools for busy clinicians to actually incorporate shared decision-making in their practice,” Turgeon told Healio. “For clinicians, it means we cannot currently use society guidelines to help us identify which decisions would be well suited for shared decision-making for most CV conditions or guide us in sharing these decisions with patients. We did identify a few pioneering guidelines that did really well, such as the 2018 ACC lipid guidelines and the 2022 CCS cardiometabolic guidelines.”
Turgeon said guideline authors must incorporate shared decision-making in recommendations when it is appropriate.
“Fortunately, there is guidance from several organizations such as the Guidelines International Network (GIN) and the United Kingdom’s National Institute for Health and Care Excellence (NICE) on how we can do this, and we can also look at the high-performing guidelines as a template for how to incorporate shared decision-making into our guidelines,” Turgeon told Healio.
For more information:
Ricky D. Turgeon, BSc(Pharm), PharmD, ACPR, can be reached at ricky.turgeon@ubc.ca; X (Twitter): @ricky_turgeon.
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